National Policy For The Comprehensive Health Of The Black Population: perception of professors of health coursesAbstract
The study aims to analyze the knowledge and perception of health courses’ professors at a public university about the National Policy for Comprehensive Health of the Black Population (PNSIPN) and its implementation in training. This is a qualitative study characterized as descriptive research. Twenty-six professors from the Structuring Teaching Nuclei (NDEs) of health courses participated in the study. Data were collected through questionnaires and semi-structured interviews. For data analysis, content analysis was used as a methodological framework. The results show that eighteen professors claim to be unaware of the PNSIPN, eighteen assert that their course does not address the policy in its curricular organization, and twenty-three consider that there are particularities related to the health of the black population that are important to address in training. It is concluded that despite this lack of knowledge, professors are in favor of addressing the PNSIPN in health courses.
Keywords:
higher education; professional training; institutional racism.
Resumo
O estudo tem por objetivo analisar o conhecimento e a percepção dos/das docentes dos cursos da área da saúde de uma universidade pública sobre a Política Nacional de Saúde Integral da População Negra (PNSIPN) e sua implementação na formação. Trata-se de um estudo de abordagem qualitativa, caracterizado como uma pesquisa descritiva. Participaram do estudo vinte e seis docentes integrantes dos Núcleos Docentes Estruturantes (NDEs) dos cursos da área da saúde. Os dados foram coletados mediante questionário e entrevistas semiestruturadas. Para análise dos dados, utilizou-se como aporte metodológico, a análise de conteúdo. Os resultados demonstram que dezoito dos/das docentes afirmam desconhecer a PNSIPN, dezoito afirmam que seu curso não aborda a política em sua organização curricular e vinte e três consideram que existam particularidades relacionadas à saúde da população negra importantes de serem abordadas na formação. Conclui-se que apesar do desconhecimento, os/as docentes mostram-se favoráveis à abordagem da PNSIPN nos cursos da área da saúde.
Palavras-chave:
ensino superior; formação profissional; racismo institucional
Resumen
El estudio tiene como objetivo analizar el conocimiento y la percepción de docentes de carreras de salud de una universidad pública sobre la Política Nacional de Salud Integral de la Población Negra (PNSIPN) y su implementación en la formación. Se trata de un estudio cualitativo, caracterizado como investigación descriptiva. Participaron del estudio veintiséis docentes que formaron parte de los Centros Docentes Estructurantes (END) de carreras del área de salud. Los datos se recogieron mediante un cuestionario y entrevistas semiestructuradas. Para el análisis de los datos se utilizó el análisis de contenido como aporte metodológico. Los resultados demuestran que dieciocho de los docentes afirman desconocer el PNSIPN, dieciocho afirman que su curso no aborda la política en su organización curricular y veintitrés consideran que existen particularidades relacionadas con la salud de la población negra que es importante tener en cuenta. abordados en la formación. Se concluye que a pesar del desconocimiento, los docentes están a favor del enfoque del PNSIPN en las carreras de salud.
Palavras clave:
educación superior; formación profesional; racismo institucional.
1 Introduction
Health is a universal right to be provided by the Unified Health System (SUS in Portuguese acronym), regardless of color, race, religion, place of residence, and sexual orientation, as guaranteed by the Federal Constitution of 1988 (Brasil, 1988). However, it is not enough to guarantee the right to care within SUS; it is also necessary to pay attention to health determinants, considering social, economic, cultural, psychological, behavioral, and ethnic/racial factors (Buss; Pellegrini Filho, 2007), for planning public policies that align with the health demands of populations, especially the black population.
Thinking about access to health means reflecting on aspects of equity, which, according to Turner (1986), relates to three types to be considered to achieve equity in health: equality of opportunities, conditions, and outcomes. However, due to a lack of equal opportunities, people do not achieve equal conditions, resulting in unequal outcomes.
When addressing the health of the black population, it is essential to pay attention to the issues of racism affecting this group, as “racism emerges as a social determinant of health, given that the concentration of wealth and power, as well as environmental and living conditions, and the factor of race, are associated with health inequities” (Jesus, 2020, p. 4). Racism can manifest in various forms, from the individual level and interpersonal relationships to institutional and structural levels, where it reveals itself in even more complex ways (Werneck, 2016). In turn, Institutional Racism1 (Brasil, 2009, p. 16) can be considered a barrier to accessing health services for the black population, as it promotes the invisibility of their needs by health professionals (Kalckmann et al., 2007).
Considering the specificities of the health of the black population and aiming to minimize situations of racism affecting this group, the National Policy for Comprehensive Health of the Black Population (PNSIPN in Portuguese acronym) was established in 2009 through Ordinance No. 992, of May 13, created from a pact of commitments between the Ministry of Health and the Special Secretariat for Policies for the Promotion of Racial Equality (Brasil, 2009). The PNSIPN seeks to “promote the comprehensive health of the black population, prioritizing the reduction of ethnicracial inequalities, combating racism and discrimination in SUS institutions and services” (Brasil, 2009, p. 19). Among its guidelines is “the inclusion of themes of racism and health of the black population in the training and continuing education processes of health workers and in the exercise of social control in health” (Brasil, 2009, p. 18).
In this sense, the PNSIPN stands as one of the policies that SUS has sought to establish as a guiding principle for the training and practice of health professionals, aiming to align health education guidelines with emerging paradigms, realities, and demands related to the historical, social, economic, and cultural moment of society (Brasil, 2009; Conceição; Riscado; Vilela, 2018). Thus, Monteiro, Santos, and Araújo (2021, p. 4) affirm that "the practice of this policy is an important contribution to the consolidation of SUS, ensuring universal and equitable access to health as a condition for participatory democracy." However, according to the authors, little has been done to ensure that the guidelines of the PNSIPN materialize.
Nevertheless, the inclusion of ethnic-racial relations is still seen as a gap in the curricula and programs of training courses for health professionals, demonstrating that the existence of legislation on including this theme in higher education does not guarantee its effectiveness (Conceição; Riscado; Vilela, 2018). In this perspective, Monteiro (2016) mentions in his study that there are still few movements in health courses to consider the topic in question as content in the training of students.
Starting from the gaps observed in the literature and understanding the importance of addressing aspects of ethnic-racial issues during health training, the study aims to analyze the knowledge and perceptions of teachers in health courses at a public university regarding the National Policy for Comprehensive Health of the Black Population and its implementation in education.
2 Method
This is a qualitative study characterized as descriptive research. The study was approved by the Research Ethics Committee of the researchers' institution under the number of opinion 5.257.880 and followed the guidelines of Resolution No. 510/16 of the National Health Council.
The study population consisted of sixty professors from the Structuring Teaching Nuclei (NDEs in Portuguese acronym) of health-related courses at the Federal University of Pampa (Unipampa), including Physical Education, Nursing, Pharmacy, Physiotherapy, Nutrition, Medicine, and Veterinary Medicine. All professors were invited to participate in the study, and the sample included all those who voluntarily agreed to take part. It is worth noting that a minimum number of three participants from each NDE was intentionally established, and when this was not met, the invitation was resent to ensure minimum representation from each course.
Data collection was carried out from December 2021 to February 2022 and took place in two stages. In the first stage, an online questionnaire was sent via Google Forms to the professors, along with the Informed Consent Form (ICF), in which participants indicated their awareness of the ethical aspects of the study and its stages.
The questionnaire contained both open and closed questions to identify sociodemographic indicators such as sex, ethnicity (skin color), duration of professional ties, and integration into the NDE. In this stage, twenty six professors responded, and interviews were scheduled with them.
In the second stage of the research, semi-structured interviews were conducted to determine the professors' knowledge of the PNSIPN and their perceptions regarding the implementation of this policy in the training of academics in health courses. The interview was guided by a script specifically developed for this study, with individual sessions conducted via the Google Meet virtual platform. Audio was captured during all interviews, recorded using the platform’s built-in recording feature, with participants’ permission. After data collection, the interviews were transcribed for later analysis. To ensure participant anonymity, they were labeled using a convention consisting of the letter "D" followed by a number, such as D1, D2, D3, and so on.
For data analysis, descriptive analysis of the sociodemographic aspects was performed based on absolute frequencies. The analysis of open-ended questions primarily employed the content analysis method proposed by Bardin (2016), which is based on categorical analysis, breaking down responses into categories. The data underwent a classification filter according to the frequency of presence or absence of meaningful items. The content analysis consisted of three stages: a) Pre-analysis, where data organization and selection were carried out; b) Data exploration, involving coding and selection of categories; c) Treatment of results, classifying categories that emerged from the data.
3 Results and Discussion
Of the twenty six study participants, twenty are female. Regarding ethnicity, twenty four professors identify as white and two as black. Additionally, seven participants reported having less than five years of teaching experience at the University, thirteen reported having between five and ten years, and six professors have more than ten years. Concerning the duration as members of the NDE, nine have participated for less than three years, ten for three to five years, five participants for five to ten years, and two for more than ten years.
The number of NDE professors who did not agree to participate in the study also represents a significant result, as of the sixty invited professors, twenty six responded and agreed to participate in the research stages. In this sense, one can reflect on the meaning that this data expresses, as the refusal, disregard, and nonparticipation may indicate how difficult it is to obtain data for the production of knowledge about the health of the black population, revealing how institutional racism is present in the details (Silvério; Dias, 2019).
From the analysis of the interview responses regarding knowledge of the PNSIPN, it was found that eighteen professors stated they were not aware of the policy, as shown in Table 1.
Knowledge of NDE Teachers about the National Policy for Comprehensive Health of the Black Population.
Regarding knowledge of the PNSIPN, there is a scarcity of studies investigating the awareness among professors in health-related courses. However, the study by Monteiro, Santos, and Araujo (2021) highlights, through collective production, the lack of knowledge about the policy among those responsible for health courses and, consequently, the implications of this ignorance.
In a study conducted with residents and preceptors in the Family Health residency programs in Florianópolis-SC, 75.65% of participants reported being aware of the existence of the PNSIPN; however, only 16.52% of them stated that they had read it, and 85.22% of participants in this study indicated that they had not utilized it in their professional practice (Matos; Tourinho, 2018).
Similar to the present study, the lack of awareness regarding the PNSIPN is noted in other studies involving health professionals, highlighting the need for this topic to be more widely disseminated and emphasizing the importance of initial and continuing education for professionals. This importance and necessity are reinforced by reports from SUS managers, who indicate that the lack of knowledge about the policy and its significance is one of the challenges to implementing the PNSIPN, as it results in minimal support from professionals (Rinehart, 2013). It is also noteworthy that a study conducted with black individuals, all users of SUS, in the city of Juiz de Fora-MG (Chehuen Neto et al., 2015), found that 90.5% of participants reported being unaware of the existence of a public health policy specifically for the black population, thus reinforcing the weaknesses in policy implementation and dissemination within SUS.
Regarding the approach of the PNSIPN in the curricular organization of the course, 18 NDE professors stated that the course does not cover the PNSIPN in its curriculum, as illustrated in the following interview excerpt:
I think it would be interesting to put this on the agenda for the NDE itself (D21).
Furthermore, six participants mentioned that it may be addressed, including those who do not know or have doubts about the PNSIPN's coverage in the course curriculum. This is exemplified in the statement of Professor 1:
Honestly, I will be very sincere with you; I do not have enough knowledge to know exactly how these policies are being implemented within the course components or curriculum (D1).
Only two professors confirmed that the course does indeed address the PNSIPN in its curricular organization, as indicated in the following statements:
Yes, yes, I know it's in the PPC. The girls work on this; the girls I refer to from Collective Health II also address this issue. They hold seminars with the students, where each group brings a policy to debate and discuss. I work with a slightly more advanced collective health approach, you know? I go into their internship practice with them. So they already come with this foundation from other collective health courses (D10).
Yes, this is actually directed not only within the course in the area of education but also in extension. In our teaching projects, we also have support groups for this population, such as two projects being developed by students, professors, and TAEs that aim to address this more specific theme (D25).
The lack of focus on the health of the black population in the curriculum of these courses, identified in the present study's results, corroborates findings from the study by Silvério and Dias (2019), which, when analyzing the curricula of Medicine, Nursing, Physiotherapy, Nutrition, Physical Education, Dentistry, Psychology, and Environmental Health Management courses at the Federal University of Uberlândia, found no mandatory or elective courses that directly addressed the theme or its particularities and needs. The health of the black population was only mentioned in specific topics during the courses, such as in Medicine, where topics related to the theme were found in Collective Health II and Collective Health VII courses (Silvério; Dias, 2019). This results in a fragmented view of the topic, which, even when addressed, is restricted to the pathogenic and hygienist model of the National Policy for Comprehensive Health of the Black Population.
Similar results were found in the study by Conceição, Riscado, and Vilela (2018), which identified a silencing of the black population's health issue in the PPC of the Medicine course at the Federal University of Alagoas, noting some sporadic references to diseases considered scientifically and genetically prevalent in the black population. Such results, when combined with other studies, indicate the fragmentation of the topic across certain components in which the health of the black population is treated in the training of future health professionals, potentially impacting the care, treatment, and quality of service they will provide to this population in their professional practice (Silvério; Dias, 2019; Faria; Silva, 2016).
When participants were asked whether there are particularities related to ethnic and racial issues that are important in the training of health students, twenty three professors affirmed that there are indeed important particularities. As noted in the statement of Professor 3:
I do believe that it is important; many knowledge aspects are constructed at the university, right? Soon, they leave that social bubble I live in and gain a broader understanding, and the professional must have this knowledge. I think this diversity must be addressed to have a professional with a somewhat broader perspective on society and the differences that exist within it (D3).
However, three interviewees felt that there are no important particularities related to ethnic and racial issues in the training of health students, as exemplified in the following statement: "Well, if we're thinking about training, all the students who enter my classroom are trained the same way. They have the same classes, the same treatment, the same guidance, right?" (D23).
Regarding what these particularities might be in terms of ethnic and racial issues in the training of health students, six categories emerged from the analysis of the responses, as listed in Table 2.
Professors’ perceptions regarding the particularities related to ethnic and racial issues in the training of health students
When questioned about the particularities related to ethnic and racial issues in the training of students, aspects related to Social Context (14) frequently emerged among the professors’ responses. Considering the aspects of the social context, the PNSIPN itself includes a set of strategies among its principles that restore the holistic view of the individual as a way to understand their health conditions (Brasil, 2009).
Institutionalization emerged as a category among the professors’ responses, with seven professors expressing concern about addressing ethnic-racial issues as a mandatory theme throughout the university context, rather than limiting it to teaching and health-related courses, thus reaffirming more effective commitments to ethnicracial equity, as proposed by the PNSIPN (Brasil, 2009). This concern is also reflected in the category of Transversal Themes (six), where professors assert that the particularities related to ethnic-racial issues should permeate undergraduate courses transversally and not be confined to one or another specific curricular component.
In contrast, six professors’ responses were directed towards the category of Curricular Component, where they mentioned that ethnic-racial issues should be addressed in specific curricular components such as anthropology or sociology, justifying the lack of focus on the topic in other curricular components, primarily due to the course workload. In this regard, the study by Silvério and Dias (2019) warns that going through the university training process without exposure to the particularities of ethnic-racial issues can be detrimental for future health professionals, as the spaces within various courses provide opportunities for discussion and learning on this matter.
When asked about their opinion regarding the theme of black population health in health curricula, twenty-two professors considered the inclusion of the topic in health curricula to be extremely important, while four expressed ignorance about the significance of the PNSIPN and mentioned in their responses that the policy could reinforce racial discrimination, as demonstrated in the following statement:
[...] I know they are discriminated against; they have all that historical issue, but if they want equal rights, why do they need something just for them? I know that, like Indigenous people, they are populations that have been heavily affected throughout history and have faced discrimination and have not had the same opportunities. But I think it’s important to talk about, just not necessarily in a specific subject. Just like the issue of quotas, I don’t think there should be racial quotas, but rather quotas based on the level of education that the child or adolescent has achieved (D16).
Supporting this finding, other studies have also found that policies like the PNSIPN tend to reinforce racial discrimination (Matos; Tourinho, 2018; Chehuen Neto et al., 2015). According to Chehuen Neto et al. (2015), more than half of the sample (52.7%) stated that policies like this tend to reinforce racial discrimination.
However, in research conducted with health professionals involved in residency programs, the majority of participants also considered the PNSIPN important (82.61%), while 16.52% stated that they see it as important but believe that such policies tend to reinforce racial discrimination (Matos; Tourinho, 2018). These findings are very similar to those of the present study, demonstrating that a majority recognizes the policy as important in the pursuit of health equity.
From the inquiry about professors’ opinions on the theme of black population health in the curricula, they pointed out possibilities that could facilitate the approach to the topic, as presented in Table 3.
Possibilities for addressing the theme of Black Population Health in the Curricula of Health Courses.
In light of the perspectives on including the discussion of black population health in the curricular organization of undergraduate health courses, twelve professors mentioned the approach to aspects of the PNSIPN in the Content of the Curriculum Structure, to be treated transversally across curricular components, integrating with specific knowledge without restricting the discussion to a particular curricular component. Additionally, the possibility of expanding the discussion to other populations, such as the Indigenous population, was also mentioned. Another alternative that emerged among the professors’ responses is the investment in Dialogue Spaces (seven), with university extension cited as a potential strategy to address the PNSIPN, encouraging reflections on black population health both in the university context and in practices developed in health services.
Continuous training for higher education faculty also emerged among the categories, present in the responses of three professors. Continuous training is highlighted as an important strategy by the professors, as it is through this training that many will be introduced to the PNSIPN and the sociocultural aspects associated with black population health, contributing to raising awareness on the topic and facilitating discussions on other issues, such as ethnic-racial relations and institutional racism.
The possibilities outlined by the professors are essential, as they not only provide benefits to the health of the black population, which will receive dignified care aligned with human rights in the long term, but also benefit student training. This enables undergraduate students to develop a multicultural perspective on health and the ability to establish therapeutic professional relationships that are culturally competent, grounded in an anti-racist perspective (Silvério; Dias, 2019). Consequently, this fosters debate on aspects related to institutional racism, which persists in our society, affecting both the health and education sectors.
4 Final considerations
In analyzing the knowledge and perception of professors regarding the PNSIPN and its implementation in the training of students in health courses, it was found that most professors are unaware of the policy and perceive that health courses, in general, do not address the PNSIPN in their curricular organization, highlighting a gap in curricula and professional health training, corroborating findings in the literature. Despite this lack of knowledge, the majority of professors expressed support for the policy's approach, indicating the importance of addressing ethnic-racial issues, such as considering the social context, the transversality of the discussion across curricular components, and the discussion of human rights as crucial topics in student training.
More broadly, the results reflect the limited visibility of black population health, not only in the health courses of the investigated university but in society as a whole. This underscores the urgency of addressing ethnic-racial issues and their specificities, including institutional racism, which affects the health of this population during professional training and ongoing education for professors, given that the training of health professionals is a fundamental strategy for ensuring healthcare for the black population.
Furthermore, it is essential that this topic is included in the Pedagogical Projects of the Courses, as these documents guide teaching practice. Finally, it is suggested that future studies promote discussions on the sociocultural aspects influencing instances of racism by health professionals, outlining strategies to break such practices, complementing the findings of the present study.
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1
Institutional racism constitutes the systematic production of ethnic-racial segregation in institutional processes. It manifests through discriminatory norms, practices, and behaviors adopted in everyday work, resulting from ignorance, lack of attention, prejudices, or racist stereotypes. In any case, it always places individuals from discriminated racial or ethnic groups at a disadvantage in accessing benefits produced by institutional actions.
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Section Editor:
André Pires | Layout Editor: Silmara Pereira da Silva Martins
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Translation:
Carlos Augusto Riella de Melo. E-mail: guto.riella@gmail.com
